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Consent Form
First Name
Last Name
Date of Birth
Phone
Email
Emergency Contact
What is your skin goals ?
Are you pregnant or breastfeeding?
Yes, I'm pregnant
Yes, I'm breastfeeding
None of the above
Please share with us your facial experience
First time getting a facial
Yes, I’ve had a facial before
I get facials regularly
Please share with us your skincare knowledge
I'm a newbie.
I'm pretty good with my skin.
I'm the skincare guru among my friends & family
What do you use at home? (Select all that apply)
Cleanser
Exfoliant
Mask
Toner
Serum
Moisturizer
Eye Cream
Facial Oil
Sunscreen
None
Do your at-home products contain any active ingredients like…
Glycolic Acid
Salicylic Acid
Lactic Acid
Retinol
Accutane
Steriods
Not sure
How would you describe your skin type?
Oily
Dry
Combination
Sensitive
Normal
Not Sure
How would you describe your history with breakouts?
I rarely experience breakouts
I frequently experience breakouts
I experience breakouts on my chest and back
I’ve had breakouts since puberty
Do you typically experience seasonal allergies?
Yes
No
Have you recently had any of the following? (select all that apply)
Open wounds
Sunburn/tanning
Recent waxing
Cold sores
Laser treatment
Microdermabrasion
Unsure
Do you have any topical allergies? (Select all that apply)
Nut
Fruit
Soy
Seed
Algae
Salicylic Acid
Beeswax
Aspirin
Latex
Essential Oils
Fragrances
None
Other
If selected "Other", please provide more details:
Do you ever experience redness, burning, or itching on your skin?
Yes
No
Are you currently taking or have you taken Accutane/Isotretinoin?
Yes, currently taking it
Stopped within the last 6 months
Stopped over 6 months ago
No
Are you taking any of the following prescription medications?
Oral antibiotics
Topical antibiotics
Steroids
Antifungal
Antivirals
Immune suppressants
Blood thinners
None
Do you use any prescription skin topicals?
Yes
No
Have you had facial surgery in the last 6 months?
Yes
No
Have you been diagnosed with any of the following conditions?
Asthma
Eczema
Epilepsy
Diabetes
Current or recent cancer treatment
None
Do you have any of the following?
Pacemaker
Metal implants
Facial piercings
None
Massage Pressure Preference
What level of pressure do you prefer for facial massage and touch points?
Light pressure
Medium pressure
Heavy pressure
No additional touch
Skip neck/shoulder massage
Personal Comfort Preferences
Help us tailor your experience:
Sensitive to strong heat
Sensitive to bright lights
Easily claustrophobic
Would like a blanket for extra comfort
Prefer to avoid strong aromas
Photo & Marketing Consent
Yes, I consent to before/after photos for marketing use
Yes, I consent to before/after photos for marketing use (covering eyes/not full face)
Yes, I consent to photos for internal documentation only
By checking this box, I consent to receive transactional messages related to my account, orders, or services I have requested. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Message & Data rates may apply.Reply HELP for help or STOP to opt-out.
By checking this box, I consent to receive marketing and promotional messages, including special offers, discounts, new product updates among others. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.
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